title: In-hospital and 30-day outcomes after tibioperoneal interventions in the US Medicare population with critical limb ischemia.
abstract: OBJECTIVE
  Catheter-based revascularization has emerged as an alternative to surgical bypass for the tibioperoneal vessels. The purpose of this analysis was to describe the outcomes of tibial angioplasty interventions for critical limb ischemia (CLI) in the hospitalized Medicare population, to examine in-hospital complications, to define the 30-day readmission and mortality rates, and to assess secondary procedures performed in this population.
  
  
  METHODS
  In-patients with CLI undergoing tibioperoneal angioplasty were identified using The Centers for Medicare & Medicaid Services in-patient claims for 2005 to 2007. In-hospital complications, mortality, 30-day secondary procedures, and 30-day rehospitalization after discharge were described.
  
  
  RESULTS
  A total of 13,258 in-patients underwent tibioperoneal angioplasty (54.2% men; 75.7% white, 17.1% African American; 42.8% gangrene, 46.7% rest pain, 10.5% claudication) and 29.3% had a stent, 47.3% had femoral-popliteal angioplasty, and 20.1% had atherectomy during their initial procedure. Initial hospital complications included renal complications (8.1%), respiratory complications and pneumonia (5.1%), and cardiac complications with acute myocardial infarction (3.2%). Mortality in-hospital was 2.8% and at 30 days was 6.7%. Thirty-day rehospitalization rate was 29.6%. Thirty-day reinterventions included repeat angiogram (8.5%), repeat tibioperoneal angioplasty (3.2%), open bypass (2.1%), and lower extremity amputations (23.8%). Gangrene was the most frequent diagnosis at rehospitalization (13.5%). Patients with gangrene as an indication for tibioperoneal angioplasty were 1.8 times (95% confidence interval [CI], 1.56-2.10) as likely as patients with rest pain to be rehospitalized during 30 days after discharge. Among comorbidities, predictors of 30-day rehospitalization included chronic renal failure (odds ratio [OR], 1.4; 95% CI, 1.27-1.52), chronic pulmonary disease (OR, 1.1; 95% CI, 1.01-1.25), and congestive heart failure (CHF; OR, 1.1; 95% CI, 1.01-1.22). About one-quarter of patients (23.8%) within 30 days after their initial procedure underwent amputation at any level of the lower limb.
  
  
  CONCLUSIONS
  Tibioperoneal angioplasty is associated with frequent in-hospital complications, an overall 30-day amputation rate of 23.8% for all procedures and indications, and a 30-day rehospitalization rate of almost 30%. Further detailed analysis of tibioperoneal intervention is essential to define best treatment strategies and to minimize complications and readmission rates.
authors.affiliation: University of Medicine and Dentistry of New Jersey - Robert Wood Johnson Medical School, Division of Vascular Surgery, The Surgical Outcomes Research Group and The Department of Medicine, New Brunswick, NJ 08903-0019, USA. vogelto@umdnj.edu
authors.forename: Todd R
authors.initials: TR
authors.lastname: Vogel
authors.forename: Viktor Y
authors.initials: VY
authors.lastname: Dombrovskiy
authors.forename: Jeffrey L
authors.initials: JL
authors.lastname: Carson
authors.forename: Alan M
authors.initials: AM
authors.lastname: Graham
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000671:Amputation, Surgical; D017130:Angioplasty / Q000009:adverse effects / Q000295:instrumentation / Q000401:mortality; D016009:Chi-Square Distribution; D016638:Critical Illness; D005260:Female; D006801:Humans; D007511:Ischemia / Q000401:mortality / Q000601:surgery / Q000628:therapy*; D023821:Limb Salvage; D016015:Logistic Models; D035002:Lower Extremity / Q000098:blood supply*; D008297:Male; D006278:Medicare; D016017:Odds Ratio; D010359:Patient Readmission; D019233:Retreatment; D018570:Risk Assessment; D012307:Risk Factors; D015607:Stents; D016909:Tibial Arteries; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States